Maternal health care utilization following the implementation of the free maternal health care policy in Ghana: analysis of Ghana demographic and health surveys 2008-2014.

BACKGROUND: In July 2008, Ghana introduced a 'free' maternal health care policy (FMHCP) through the national health insurance scheme (NHIS) to provide comprehensive antenatal, delivery and post-natal care services to pregnant women. In this study, we evaluated the 'free' policy impact on antenatal care uptake and facility-level delivery utilization since the policy inception. METHODS: The study used two rounds of repeated cross-sectional data from the Ghana Demographic and Health Survey (GDHS, 2008-2014) and constructed exposure variable of the FMHCP using mothers' national health insurance status as a proxy variable and another group of mothers who did not subscribe to the policy. We then generated the propensity scores of the two groups, ex-post, and matched them to determine the impact of the 'free' maternal health care policy as an intervention on antenatal care uptake and facility-level delivery utilization, using probit and logit models. RESULTS: Antenatal care uptake and facility-level delivery utilization increased by 8 and 13 percentage points difference, observed coefficients; 0.08; CI: 95% [0.06-0.10]; p < 0.001 and 0.13; CI: 95% [0.11-0.15], p < 0.001, respectively. Pregnant women were 1.97 times more likely to make four plus [a WHO recommended number of visits at the time] antenatal care visits and 1.87 times more likely to give birth in a health care facility of any level in Ghana between 2008 and 2104; aOR = 1.97; CI: 95% [1.61-2.4]; p < 0.001 and aOR = 1.87; CI: 95% [1.57-2.23]; p < 0.001, respectively. CONCLUSIONS: Antenatal care uptake and facility-level delivery utilization improved significantly in Ghana indicating a positive impact of the FMHCP on maternal health care utilization in Ghana since its implementation.

Evaluating the impact of maternal health care policy on stillbirth and perinatal mortality in Ghana; a mixed method approach using two rounds of Ghana demographic and health survey data sets and qualitative design technique.

BACKGROUND: Stillbirth and perinatal mortality issues continue to receive inadequate policy attention in Ghana despite government efforts maternal health care policy intervention over the years. The development has raised concerns as to whether Ghana can achieve the World Health Organization target of 12 per 1000 live births by the year 2030. PURPOSE: In this study, we compared stillbirth and perinatal mortality between two groups of women who registered and benefitted from Ghana's 'free' maternal health care policy and those who did not. We further explored the contextual factors of utilization of maternal health care under the 'free' policy to find explanation to the quantitative findings. METHODS: The study adopted a mixed method approach, first using two rounds of Ghana Demographic and Health Survey data sets, 2008 and 2014 as baseline and end line respectively. We constructed outcome variables of stillbirth and perinatal mortality from the under 5 mortality variables (n = 487). We then analyzed for association using multiple logistics regression and checked for sensitivity and over dispersion using Poisson and negative binomial regression models, while adjusting for confounding. We also conducted 23 in-depth interviews and 8 focus group discussions for doctors, midwives and pregnant women and analyzed the contents of the transcripts thematically with verbatim quotes. RESULTS: Stillbirth rate increased in 2014 by 2 per 1000 live births. On the other hand, perinatal mortality rate declined within the same period by 4 per 1000 live births. Newborns were 1.64 times more likely to be stillborn; aOR: 1.64; 95% [CI: 1.02, 2.65] and 2.04 times more likely to die before their 6th day of life; aOR: 2.04; 95% [CI: 1.28, 3.25] among the 'free' maternal health care policy group, compared to the no 'free' maternal health care policy group, and the differences were statistically significant, p< 0.041; p< 0.003, respectively. Routine medicines such as folic acid and multi-vitamins were intermittently in short supply forcing private purchase by pregnant women to augment their routine requirement. Also, pregnant women in labor took in local concoction as oxytocin, ostensibly to fast track the labor process and inadvertently leading to complications of uterine rapture thus, increasing the risk of stillbirths. CONCLUSION: Even though perinatal mortality rate declined overall in 2014, the proportion of stillbirth and perinatal death is declining slowly despite the 'free' policy intervention. Shortage of medicine commodities, inadequate monitoring of labor process coupled with pregnant women intake of traditional herbs, perhaps explains the current rate of stillbirth and perinatal death.

Impact of free maternal health care policy on maternal health care utilization and perinatal mortality in Ghana: protocol design for historical cohort study.

BACKGROUND: Ghana introduced what has come to be known as the 'Free' Maternal Health Care Policy (FMHCP) in 2008 via the free registration of pregnant women to the National Health Insurance Scheme to access healthcare free of charge. The policy targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare. PURPOSE: This study seeks to measure the contribution of the FMHCP to maternal healthcare utilization; antenatal care uptake, and facility delivery and determine the utilization impact on stillbirth, perinatal, and neonatal deaths using quasi-experimental methods. The study will also contextualize the findings against funding constraints and operational bottlenecks surrounding the policy operations in the Upper East Region of Ghana. METHODS: This study adopts a mixed-method design to estimate the treatment effect using variables generated from historical data of Ghana and Kenya Demographic and Health Survey data sets of 2008/2014, as treatment and comparison groups respectively. As DHS uses complex design, weighting will be applied to the data sets to cater for clustering and stratification at all stages of the analysis by setting the data in STATA and prefix Stata commands with 'svy'. Thus, the policy impact will be determined using quasi-experimental designs; propensity score matching, and difference-in-differences methods. Prevalence, mean difference, and test of association between outcome and exposure variables will be achieved using the Rao Scot Chi-square. Confounding variables will be adjusted for using Poisson and multiple logistics regression models. Statistical results will be reported in proportions, regression coefficient, and risk ratios. This study then employs intrinsic-case study technique to explore the current operations of the 'free' policy in Ghana, using qualitative methods to obtain primary data from the Upper East Region of Ghana for an in-depth analysis. DISCUSSION: The study discussions will show the contributions of the 'free' policy towards maternal healthcare utilization and its performance towards stillbirth, perinatal and neonatal healthcare outcomes. The discussions will also centre on policy designs and implementation in resource constraints settings showing how SDG3 can be achievement or otherwise. Effectiveness of policy proxy and gains in the context of social health insurance within a broader concept of population health and economic burden will also be conferred. PROTOCOL APPROVAL: This study protocol is registered for implementation by the Ghana Health Service Ethical Review Committee, number: GHS-ERC 002/04/19.

The nature of leadership style in nursing management.

The purpose of this study was to explore the nature of leadership styles used by nurse managers, and describe staff nurses' perceptions of leadership styles. Effective leadership among nurse managers has been associated with staff nurse job satisfaction and retention. Twenty staff nurses from two hospitals in Ghana responded to tape-recorded interview questions. Four themes emerged from inductive analysis of the data. Findings suggest that nurse managers employed intimidation and minimal consultation to control their employees. The study further indicated that nurse managers were perceived as 'figure-heads', who are weak and inarticulate at the level of policy planning and implementation. It was therefore concluded that staff nurses in the study site hospitals lack confidence, trust and satisfaction with the current style of leadership. Staff nurses preferred a more proactive, articulate and independent nursing leadership at the top level. It is recommended that effective leadership training be instituted for prospective nurse managers before appointments are made into management and administrative positions.